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Partograph explained to details – Aminu Khadeejat

OBJECTIVES
At the end of this seminar presentation the audience should be able to:
–  Define key words.
–  Say the history of partograph.
– Enumerate the component of partograph.
–  Plot a partograph.
–  Enumerate the factors that contribute to underutilization of partograph.
–  List the importance of partograph to midwifery practice.

 

INTRODUCTION
The partograph is a very useful graphical record of the course of labour that serves optimum purpose
when used properly by the caregiver. Research evidence shows that proper use equates remarkable
reduction in the incidence and outcome of prolonged and obstructed labour. The knowledge and use of
this tool is an important step in deciding the appropriate intervention that contributes to safe delivery
process.
A considerable number of women suffer complications from labour and some of these complications
result in maternal and infant mortality. According to recent global estimates, about 289, 000 women die
annually from pregnancy related complication. The partograph is a sigmoid curve tool that can be used to
assess the progress of labour and identify when interventions is necessary. Approximately 300,000
maternal deaths occurred globally in 2013, of which 98% occurred in developing countries. On the
average 230 women die per 100,000 live births every year in developing countries. Prolonged labour is a
major cause of maternal mortality and usually results from neglected obstructed labour. The partograph
as a graphic assessment is recommended for routine monitoring of the 1 st stage of labour to help birth
attendant identify deviations from normal labour process and prevent prolonged labour and its
complications.

DEFINITION OF TERMS
Midwifery record: Midwifery record is a legal document that must be kept meticulously by
midwives. They may go before midwifery council conduct committee and usually examined in
the audit process of statutory supervision in relation to clinical negligence (Fraser et al., 2009).

Labour: this is the spontaneous onset of rhythmic uterine contractions increasing with intensity
and frequency and accompanied with progressive cervical dilatation and spontaneous vaginal
delivery of the baby, placental and it membranes.

First stage of labour: this is the period from the onset of labour till full dilatation of the cervix.

Latent phase: the period of cervical dilation within 0 to 3centimeter.

Active phase: the period from 4centimeter cervical dilatation till full dilatation

Midwifery: this is a health care profession in which the provider gives prenatal care to expectant
mothers, attend the birth of the baby and provide postpartum care to the mother and the infant.

Midwife: a midwife is a person who, having been regularly admitted into a midwifery educational
programme, has successfully completed the prescribed course of studies in midwifery and has
acquired the requisite qualifications to be registered and or legally licensed to practice midwifery
(WHO).

Partograph: a pre-printed paper with a visual graphical representation of observations on women
and fetus during the course of labour. (World Health Organization, 2015).

Management tool: This is a device that is designed for the purpose of regulating, guiding or
administering a process.

Labour management: this is the reflection on intervention and timing of care in other to optimize
the wellbeing of the woman and her baby during the course of labour. (sellers, 2007)

HISTORY OF PARTOGRAPH
The partograph was designed by Philpott in 1971 in Harare, Zimbabwe. He introduce the concept of
‘‘ALERT’’ and ‘’ACTION’’ lines in 1972. By 1973 the partograph was already considered a simple
device used to distinguish normal labour from abnormal labour as it was adopted and used to monitor
15,000 deliveries within 18 months (Studd, 1973). The observations which are carried out on the woman
during labour and the accurate recording of these observations are known as the monitoring of labour.
World Health organization (WHO) launched the partograph in 1987 as a safe motherhood initiative
following a multicentre trial in South Asia that involved 35,484 women (WHO, 1994). The partograph
was endorsed and modified by the World Health Organization (WHO), it does not have a latent phase and
the active phase starts at 4cm cervical dilatation. While the composite partograph was introduced in
Ghana in 1989 as part of the Safe Motherhood Initiative’s Life Saving Skills, the modified WHO
partograph currently being used was introduced in 2000.

THE PARTOGRAPH
In recent years, partograph also known as partogram has been widely accepted as an effective means of
recording the progress of labour. It is a chart on which salient features of labour are entered in a visual
graphic form to provide the opportunity for early identification of deviation from normal. It was initially
introduced as an early warning system to detect labour that was not progressing normally. This would
allow for timely transfer to a referral centre, for augmentation or caesarean section as required. The
partograph indicates when augmentation is needed, and can point to possible cephalopelvic disproportion
before labour becomes obstructed.
It increases the quality and regularity of observations made on the mother and fetus, and it serves as a
one-paged visual summary of the relevant details of labour. The partograph has been used in a number of
countries and has shown to be effective in preventing prolonged labour, in reducing operative
intervention, and improving the neonatal outcome. The partograph remains an integral part of intrapartum
record-keeping. However, it is a tool only as good as healthcare professional who is using it.

COMPONENTS OF A PARTOGRAPH
The partograph is divided into sections for:
-Fetal well-being.
-Progress of labour.
-Maternal condition.

FETAL WELLBEING: the fetal heart rate is checked and recorded every 15-30 minutes after a
contraction in the first stage, and every 5 minute in the second stage. If abnormalities are noted,
urgent delivery can be considered.

 

1. Liquor; the colour and consistency (thick or thin) of the amniotic fluid is noted, it may be clear,
meconium stained, bloody or absent. Meconium stain suggests fetal distress, and closer
monitoring of fetus is indicated.
2. Moulding; the degree of overriding of the skull bones. Are the bones separated and sutures felt,
bones just touching, bones are overlapping or bones are severely overlapping?

PROGRESS OF LABOUR
-Uterine contractions: Frequency, duration and strength of uterine contractions (assessed by
palpation) should be recorded every 30 minutes.
-Vaginal examination; this should be done every 4 hours to assess cervical dilatation and
effacement, descent of the fetal head (to confirm findings from abdominal examination) and
moulding of skull bones. More frequent examination is undertaken when necessary.
-Medications and intravenous infusions such as oxytocin, pethidine, normal or dextrose saline.
-Alert and action lines; the alert line starts at 4centimeter of cervical dilatation and its travels
upwards to the points of expected full dilatation (10cm) of the cervix at the rate of 1centmeter per
hour the action line is parallel to the alert line and 4hours to the right of the alert line.

MATERNAL CONDITION
Record pulse rate every 30minutes, blood pressure and temperature every 4hours, urine output
and dipstick testing for protein, acetone and glucose after voiding, and record fluids and drugs
administered. If the findings become abnormal, increase frequency of observation and testing
will be required, and intervention may be implemented.

KEY PRINCIPLES TO USING PARTOGRAPH
-The partograph is used to record events of the first stage of labour. It is important to note that the
partograph is a tool for managing labour progress only.
-Cervical dilatation should be plotted first on the partograph.
-Only start a partograph when you have checked that there are no complications of pregnancy that
requires immediate action.
-The partograph is filled out during the labour not after birth.
-During labour the partograph must be kept in labour room.
-The partograph is filled in and interpreted by trained personnel (midwife or obstetrician).
-If progress of labour is satisfactory the plotting of cervical dilatation will remain to the left of the
alert line.
-When admission takes place in the active phase of labour the cervical dilatation is plotted on the
alert line
-Filling in partograph should be stopped when complications requiring urgent delivery arise. Begin
plotting at the “zero” hour on the partograph.
-Notes should be legible, dated and timed.
-Enter the outcome of delivery.

HOW TO PLOT PARTOGRAPH
-MATERNAL INFORMATION: this includes the name, age, parity, gestational age, date/time
of admission, time of rupture of membrane, duration of labour and the folder number. The
hospital name is sometimes included. This information is recorded at the top portion of the
partograph.

– FETAL WELLBEING:
i. Fetal heart rate; this is depicted with a dot (.)on the line or in the box
ii. Characteristic of liquor; this is indicated with ‘C’ if clear, ‘M’ if meconium stained, ‘B’ if
bloodstained, ‘I’ if membranes are intact, ‘R’ for ruptured membranes and ’A’ if absent.
iii. Moulding; ‘O’ indicates that bones are separated and sutures can be felt; ‘+’ means that
bones are just touching each other; ‘++’ indicates that bones are overlapping but can be
reduced; ‘+++’ means that severely overlapping and irreducible.
LABOUR PROGRESS:
i. Cervical dilatation; this is marked with a cross (x), start at 4cm cervical dilatation.
ii. Alert line; starts at 4centimeter of cervical dilatation at the rate of 1centimeter per
hour. If plotting crosses to the right side of this line it indicates slow progress of
labour, necessary intervention should be taken.
iii. Action line; parallel to the alert line, it is 4 hours to the right.
iv. Descent; recorded as a circle (O) at every vaginal examination.
v. Hours; this refers to the time elapsed since the onset of active phase of labour
vi. Time; record the actual time of events, entries should be made in relation to time when
the observations are made.
vii. Contractions: chart every 30 minutes, count the number of contractions in 10 minutes
and its duration in seconds.
<20seconds – mild contractions indicated with dots(…),
20- 40seconds – moderate contractions indicated with strokes(///),
>40 seconds – strong contractions indicated with deep shading.
viii. Oxytocin; this is recorded in units per intravenous infusion and drop per minute.

ix. Drug given; record any additional drugs given.

MATERNAL CONDITION:
i. Pulse; record every 30minutes with a dot, can either be on the line or in the box.
ii. Blood pressure; this is mark with an arrow, right on the line or in the box.
iii. Temperature; record every 4hours with a dot.
iv. Urine; record presence or absence of albumin, glucose or acetone any time urine is
passed. Measure and record the volume passed.

EXAMPLE

A 29years old G3P2, Mrs A.P. was brought into your health facility at 7pm. LMP- 6/7/17, EDD-
13/4/18. On vaginal examination, cervical dilatation- 5cm, membrane intact, descent 3/5, moulding-
bones just touching, fetal heart rate 130b/m, contractions two in 10minutes lasting 30 seconds, maternal
blood pressure 110\70, pulse rate 74beat per minute, temperature 36.6. degree Celsius, volume of urine
250 millimeters, no abnormalities detected in the urine.

-At 7:30pm, fetal heart rate 138b/m, pulse 76b/m, contractions 3 in 10minutes lasting
28seconds
-At 8:00pm, fetal heart rate 136b/m, pulse 74b/m, contractions 3 in 10minutes lasting
30seconds
-At 8:30pm, fetal heart rate 140b/m, pulse 80b/m, contractions 3 in 10minutes lasting
35seconds
-At 9:00pm, fetal heart rate 136b/m, pulse 80b/m, contractions 3 in 10minutes lasting
40seconds, urine output 250mL, no abnormalities detected,

– At 9:30pm, fetal heart rate 140b/m, pulse 84b/m, 4 contractions in 10minutes lasting
41seconds.
– At 10:30pm, fetal heart rate 138b/m, pulse 86b/m, 4 contractions in 10minutes lasting
45seconds.
– At 11:00pm, cervical dilatation is 9cm, descent 1/5, bones just touching each other, liquor
is clear, contractions is 4 in 10minutes lasting 50seconds, fetal heart rate is 140b/m, urine
output 200mL no abnormalities detected, blood pressure is 134/80mmhg, pulse 80b/m,
temperature 36.5.
– At 11:30pm, fetal heart rates is 140b/m, pulse 84b/m contraction is 4 in 10minutes lasting
54seconds
– At 12:00am, full cervical dilatation, descent is 0/5, fetal heart rate is 138b/m, contraction
is 5 in 10 minutes lasting 58seconds
– At 12:05am, a life male baby was delivered with an apgar score of 8 and 9 at 1 and 5
minutes respectively, weight- 3.5kg.

FACTORS AFFECTING THE EFFECTIVE USE OF PARTOGRAPH
– Time factor; the time required for the filling of partograph is considered as waste especially in a
facility that attaches less importance to partograph.
– Shortage of staff; underutilization of partograph is also attributed to shortage of staff in the
facility resulting in the ratio of one midwife to two or three labour cases.
– Lack of resources; insufficient or lack of partograph sheets affects its availability of use.
– Inadequate training of midwives and doctors in the use of partograph.

– Poor appreciation of its advantages.

ADVANTAGES OF PARTOGRPAH
– Provides information on single piece of paper at a glance.
– No need to record labor events repeatedly.
– Prediction of deviation from normal progress of labour.
– Reduce the rate of maternal and neonatal morbidity and mortality.

IMPORTANCE OF PARTOGRAPH TO MIDWIFERY PRACTICE
1. Effective standard graph for observing the progress of labour.
2. The use of partograph reduces:
– The incidence of prolonged labour.
– The number of labour cases requiring augmentation.
– The emergency caesarean section rate.
– The rate of intrapartum stillbirth.
3. Helps to make quick and logical decisions for managing labour.
4. It facilitates research.
5. Provides early detection for unsatisfactory progress of labour.
6. Allows for continuity of care.
7. Provides a basis for decision making.
8. Allows for auditing and reviewing.
9. In defense of one’s actions- no documentation no defense.
10. Simple, low cost, accessible and clear.

 

CONCLUSION
In rendering safe and quality care to clients in the practice of midwifery, the partograph plays an
important role in helping the midwife deliver competent care to the expectant mother at the end of her
pregnancy. The appropriate use of this tool, that is correct and consistent use cannot be overemphasized
as it has gone a great length in the reduction of maternal and neonatal morbidity and mortality ratios
through early detection of deviations from normal. Meanwhile the effectiveness of the partograph
depends on the ability of the midwife to use it.
The close monitoring of the progress of a woman’s labour with the partograph helps midwives make
pivotal decisions during the birthing process which has helped save the lives of many mothers and
neonates.

REFERENCES
Fraser D., Cooper M. and Nolte A., (2008). Myles Textbook for Midwives. African Edition. Churchill
Livingstone,Elsevier.

Marshall J. and Raynor M. (2014). Myles Textbook for Midwives, 16th edition. London, Elsevier.
Mathibe-Neke J., Lebeko F. and Motupa B. (2013).The partograph: A Labour Management Tool Or A
Midwifery Record?, Volume 5, http://www.academicjournals.org/IJNM .

Sellers P. (2007). Midwifery: A Textbook And A Reference Book For Midwives In Southern Africa.
Juta, South Africa.

World Health Organization (2008). Managing Prolonged And Obstructed Labour. Retrieved from
http://books.mcai.org.uk/2.3.Managing normal labour and delivery.1.5MB/part3.htm.

 

 

Writer:

Aminu Khadeejat A.

Aminukhadee@gmail.com

Lagos State school of midwifery, Igando.

 

Aminu Khadeejat A

 

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Updated: August 10, 2018 — 7:08 am

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